I would like to express my sincere gratitude to Dr. DuCoin for the opportunity to study robotic foregut surgery. As a research fellow from Israel, I am grateful for the opportunity to share this robotic approach to the Heller myotomy used at our center. The authors received no funding for this work.

This protocol follows the guidelines of our institution&#39;s human research ethics committee. Written informed consent was obtained from the patients&#39; cases reviewed for the protocol. Inclusion criteria - patients of all ages who were diagnosed with achalasia based on clinical manifestations, manometric criteria, and radiographic studies. Exclusion criteria - achalasia symptoms due to gastroesophageal malignancy.
1. Preoperative preparation
<ol>
	<li>Place patients on a liquid diet for 3 days prior to the operation in an attempt to clear the esophagus of impacted food.</li>
	<li>Place the patient in the supine position and administer general endotracheal anesthesia (GETA) via a rapid sequence induction (RSI) while holding cricothyroid pressure to reduce the risk of aspiration during intubation. To provide Cricothyroid pressure, apply manual pressure on the cricoid cartilage to occlude the esophagus. 
	NOTE: The RSI technique is conducted via the administration of appropriate anesthetic agents and neuromuscular blocking agents per the anesthesiologist&#39;s protocol.</li>
	<li>After successful endotracheal intubation, perform an esophagogastroduodenoscopy (EGD) to assess the level of achalasia severity and dislodge any solid food stuck in the esophagus, if needed (Figure 1A).
	<ol>
		<li>Ensure the endoscope is clean and properly connected to the video monitor and light source. Confirm that the water and air channels are functioning correctly, lubricate the distal end of the endoscope to facilitate insertion, and then gently insert the endoscope through the patient&#39;s mouth into the esophagus under direct visualization. 
		NOTE: Usually, there is a pop of pressure as the endoscope is passed through the gastroesophageal junction with pressure.</li>
	</ol>
	</li>
	<li>Leave the endoscope in the stomach to function as a bougie and provide counter pressure within the esophagus during the myotomy procedure.</li>
</ol>
2 Ports placement and robotic docking
NOTE: A total of four 8 mm robotic ports are required for the surgery, and there is an option to add a fifth port to serve as an assistant trocar.
<ol>
	<li>Following skin sterilization and preparation using an antiseptic solution, perform a small skin incision of approximately 1 cm using a blade at each planned trocar insertion site in order to insert the trocar into the abdominal cavity.</li>
	<li>Place the first port site at 15 cm below the xiphoid process, 1-2 cm to the left of the abdominal mid-line, using a 0&#176; 5 mm laparoscope and optical access trocar visualization technique. Use a verses needle to inflate the abdomen when needed.</li>
	<li>Attach carbon dioxide gas insufflation and inflate the abdomen to 15 mmHg. Reinsert the 0&#176; scope and inspect the abdomen for any site of potential trocar injury. Change the laparoscope to 30&#176; to facilitate additional trocar placement.</li>
	<li>Under direct vision, place three 8 mm robotic trocars in a transverse line at the level of the first port with 4-8 cm between each port (try to leave 8 cm between each port to reduce collisions within the robotic arms). Locations of robotic ports (from patient left to right) are approximately at the left anterior axillary line, left mid-clavicular line, and right mid-clavicular line (Figure 2).</li>
	<li>Place an additional assistant trocar in the right flank at the level of the right anterior axillary line, just above the level of the umbilicus.</li>
	<li>Place a Nathanson liver retractor in the xiphoid region to elevate the left lateral lobe of the liver and expose the hiatus. This will expose the entire left upper quadrant, ensuring excellent exposure for the operation.</li>
	<li>Dock the robot. Prepare the instruments, which include an advanced bipolar energy device, a cardia forceps, a fenestrated bipolar, and a hook cautery.</li>
</ol>
3 Division of phren-oesophageal ligament
<ol>
	<li>Divide the gastrohepatic ligament using the bipolar energy device to expose the right crus and phren-oesophageal membrane (Figure 3).</li>
	<li>Identify the phreno-esophageal membrane and divide it using the bipolar energy device toexpose the longitudinal muscle fibers of the esophagus. Extend and dissect the avascular plane between the esophagus and mediastinum from the right crus to the left crus after dividing the phren-oesophageal ligament.This dissection should expose the anterior surface of the esophagus.</li>
	<li>Identify and preserve the anterior vagus nerve. Elevate and dissect the anterior vagus nerve off of the esophagus to facilitate the preservation of the nerve and to ensure a complete myotomy beneath the nerve .</li>
</ol>
4 Esophageal myotomy
<ol>
	<li>Dissect the gastroesophageal fat pad on the anterior surface using an electrocautery hook from the level of the stomach to expose the GEJ; start the dissection at the distal fat pad.</li>
	<li>Extend the dissection proximally to the left crus using an electrocautery hook, and then medially dissect towards the right crus with care to preserve and protect the anterior vagus, which often courses through the medial aspect of the fat pad.</li>
	<li>Before performing the myotomy, completely expose the distal portion of the esophagus and the anterior portion of the proximal stomach to allow for the appropriate length of myotomy. 
	NOTE: The goal for myotomy length should be a minimum of 6 cm in the distal esophagus and 2 cm in the proximal stomach.</li>
	<li>Begin the myotomy just proximal to the GEJ on the side of the esophagus, approximately 1 cm proximal. This approach will help the surgeon avoid the sling fibers of the stomach, which can occasionallycause confusion during dissection.</li>
	<li>Exchange the robotic advanced bipolar instrument for the robotic hook. With great care, start the myotomy 1 cm proximal to the GE junction with a brief application of cautery energy with the robotic hook. Using traction of the robotic hook towards the anterior abdominal wall, carefully divide the esophageal muscle fibers until the esophageal mucosa is visualized.</li>
	<li>After the mucosa is visualized, repeat the traction motion of the hook (with minimal use of cautery) to tear the esophageal muscular fibers proximally onto the esophagus. Continue dissection until either the view becomes obstructed or the dissection has reached a point where repairing an injury would be challenging. Ensure that it is at least 6 cm in length (Figure 4 and Figure 5).</li>
	<li>After completing the proximal myotomy, continue the dissection down onto the side of the stomach. 
	NOTE: A technical consideration during myotomy is to prioritize the tearing of muscle fibers rather than using cautery. This helps to minimize the risk of thermal injury. However, if cautery is used, it is recommended to pull the circular fibers away from the esophagus before applying cautery. (Figure 4)</li>
</ol>
5 Post-myotomy esophago-gastro-duodenoscopy
<ol>
	<li>Perform an EGD to evaluate the GEJ. Ensure that the endoscope easily passes across the cardia and use visual inspection to ensure that there is no thermal injury (Figure 1B).</li>
	<li>Perform a leak test by inflating the esophagus and stomach with air while submerging them in water. Evaluate for the presence of gas bubbles, which could indicate a leak.</li>
	<li>After completing the myotomy,proceed with a Dor to Toupet fundoplication if indicated. 
	NOTE: If a Toupet fundoplication is performed, posterior dissection of the hiatus is necessary. However, if a Dor fundoplication is to be performed, there is no need to disturb the posterior attachments of the esophagus.</li>
	<li>Upon completing the procedure, remove the endoscope along with the liver retractor and ports.</li>
</ol>
6 Post-operative care
<ol>
	<li>In the postoperative period, administer a multi-modal pain regimen with anti-inflammatory and opioid medications. Start patients with a clear liquid diet on the day of surgery. On postoperative day 1, perform a radiographic evaluation with an upper GI series to evaluate for leaks (Figure 6B). Most patients are discharged on postoperative day 1 with instructions to follow a full liquid diet until post-operative evaluation in the surgery clinic within 2 weeks.</li>
</ol>

Treatment of Achalasia by Robot-Assisted Heller Myotomy

<ol><li>Boeckxstaens, G. E., Zaninotto, G., Richter, J. E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Achalasia%5BTitle%5D)+AND+%22Lancet%22%5BJournal%5D)">Achalasia.</a> Lancet. 383, 83-93 (2014).</li>
<li>Goyal, R. K., Chaudhury, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Pathogenesis+of+achalasia%3A+lessons+from+mutant+mice%5BTitle%5D)+AND+%22Gastroenterology%22%5BJournal%5D)">Pathogenesis of achalasia: lessons from mutant mice.</a> Gastroenterology. 39 (4), 1086-1090 (2010).</li>
<li>Leeuwenburgh, I., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Long-term+esophageal+cancer+risk+in+patients+with+primary+achalasia%3A+a+prospective+study%5BTitle%5D)+AND+%22Am+J+Gastroenterol%22%5BJournal%5D)">Long-term esophageal cancer risk in patients with primary achalasia: a prospective study.</a> Am J Gastroenterol. 105 (10), 2144-2149 (2010).</li>
<li>Campos, G. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Endoscopic+and+surgical+treatments+for+achalasia%3A+a+systematic+review+and+meta-analysis%5BTitle%5D)+AND+%22Ann+Surg%22%5BJournal%5D)">Endoscopic and surgical treatments for achalasia: a systematic review and meta-analysis.</a> Ann Surg. 249 (1), 45-57 (2009).</li>
<li>Lopushinsky, S. R., Urbach, D. R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Pneumatic+dilatation+and+surgical+myotomy+for+achalasia%5BTitle%5D)+AND+%22JAMA%22%5BJournal%5D)">Pneumatic dilatation and surgical myotomy for achalasia.</a> JAMA. 296 (18), 2227-2233 (2006).</li>
<li>Yaghoobi, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Laparoscopic+Heller%27s+myotomy+versus+pneumatic+dilation+in+the+treatment+of+idiopathic+achalasia%3A+a+meta-analysis+of+randomized%2C+controlled+trials%5BTitle%5D)+AND+%22Gastrointest+Endosc%22%5BJournal%5D)">Laparoscopic Heller's myotomy versus pneumatic dilation in the treatment of idiopathic achalasia: a meta-analysis of randomized, controlled trials.</a> Gastrointest Endosc. 78 (3), 468-475 (2013).</li>
<li>Boeckxstaens, G. E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Pneumatic+dilation+versus+laparoscopic+Heller%27s+myotomy+for+idiopathic+achalasia%5BTitle%5D)+AND+%22N+Engl+J+Med%22%5BJournal%5D)">Pneumatic dilation versus laparoscopic Heller's myotomy for idiopathic achalasia.</a> N Engl J Med. 364 (19), 1807-1816 (2011).</li>
<li>Patti, M. G., Schlottmann, F., Herbella, F. A. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Laparoscopic+Heller+myotomy+and+robotic+Heller+myotomy%3A+when+is+it+indicated.+Mini-invasive%5BTitle%5D)+AND+%22Surgery%22%5BJournal%5D)">Laparoscopic Heller myotomy and robotic Heller myotomy: when is it indicated. Mini-invasive.</a> Surgery. 6, 38(2022).</li>
<li>Campos, G. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Endoscopic+and+surgical+treatments+for+achalasia%3A+a+systematic+review+and+meta-analysis%5BTitle%5D)+AND+%22Ann+Surg%22%5BJournal%5D)">Endoscopic and surgical treatments for achalasia: a systematic review and meta-analysis.</a> Ann Surg. 249 (1), 45-57 (2009).</li>
<li>Maeso, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Efficacy+of+the+Da+Vinci+surgical+system+in+abdominal+surgery+compared+with+that+of+laparoscopy%3A+a+systematic+review+and+meta-analysis%5BTitle%5D)+AND+%22Ann+Surg%22%5BJournal%5D)">Efficacy of the Da Vinci surgical system in abdominal surgery compared with that of laparoscopy: a systematic review and meta-analysis.</a> Ann Surg. 252 (2), 254-262 (2010).</li>
<li>Huffmanm, L. C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Robotic+Heller+myotomy%3A+a+safe+operation+with+higher+postoperative+quality-of-life+indices%5BTitle%5D)+AND+%22Surgery%22%5BJournal%5D)">Robotic Heller myotomy: a safe operation with higher postoperative quality-of-life indices.</a> Surgery. 142 (4), 613-618 (2007).</li>
</ol>

Dr. DuCoin works for Intuitive Surgical, Medtronic, and Johnson &amp; Johnson. The other authors declare no competing interests.

Laparoscopic and robotic Heller myotomy is now the procedure of choice with or without fundoplication6. The primary contentious issues revolve around the necessity of fundoplication after Heller myotomy, as well as the type of fundoplication (Toupet, Dor, Nissen) to minimize GERD. Peroral endoscopic myotomy (POEM) is another option for achalasia treatment; however, this option lacks a fundoplication procedure8. Therefore, surgeons should make decisions regarding which procedures to perform based on their own experience and preferences. The critical point in myotomy is to obtain enough length of myotomy on both the esophageal and gastric sides. The gastric side myotomy is, at times, more challenging than the esophageal myotomy as there is now a serosal layer of the stomach wall, and the gastric sling fibers are present as well. During this dissection, it is also common to encounter large submucosal veins feeding into the left gastric venous system. If bleeding is encountered, it is recommended to use pressure and a thrombotic agent to stop the bleeding. Additionally, caution should be taken while using hook cautery to avoid injury to the esophageal mucosa and to prevent perforation9. If there are issues with exposure of the mediastinum during esophageal myotomy, the anterior portion of the diaphragmatic hiatus can be divided to increase exposure. However, if this is done, this should be closed with a permanent stitch at the completion of the case.
The advantages of robotic surgery compared to others are enhanced dexterity and greater precision due to better visualization with the three-dimensional view. Additionally, it gives the surgeon the ability to operate even in tight spaces, hence its utilization in pelvic surgery. A meta-analysis study showed a lower intra-operative perforation rate with robotic Heller myotomy compared to laparoscopic surgery (0% vs. 11%, respectively)10. The disadvantage of the robotic approach is reported higher cost11. The limitations of the laparoscopic approach include a poor range of motion and limited view and visual stability when compared to robotics.
In conclusion, in the hands of experienced surgeons, robotic surgery is safer and yields exceptional results due to its improved visualization, platform stability, and increased articulation of the instruments.

Achalasia is an esophageal motility disorder. The most common cause of achalasia is idiopathic, characterized by impairment of the circular and longitudinal muscular layers of the esophagus due to the destruction of the myenteric nerves in the lower esophageal sphincter (LES)1. This leads to the inability of the LES to relax. Achalasia is also associated with an increased risk of esophageal squamous cell carcinoma. The gold standard for diagnosing achalasia is manometry2,3. However, endoscopy should be performed to rule out other causes of narrowing, such as gastro esophageal junction (GEJ) malignancy and other strictures.
The treatment of achalasia is divided into surgical and non-surgical options. Non-surgical treatments include the use of drugs such as calcium channel blockers and nitrates, as well as endoscopic treatments like dilation or botulinum toxin injection. Non-surgical treatments have high recurrence rates4,5. Surgical treatment, specifically laparoscopic or robotic myotomy, originally described as the heller myotomy, can be performed with or without an anti-reflux procedure. Surgical treatment provides the best long-term treatment and relieves achalasia symptoms by dissection of the muscles in the affected part of the esophagus around the LES6.
The decision to perform a fundoplication following Heller myotomy remains controversial. In theory, anti-reflux procedures, such as the Dor or Toupet procedures, reduce the risk of gastroesophageal reflux disease (GERD) following myotomy. Peroral endoscopic myotomy (POEM) has been developed as an option in the treatment of achalasia. Through a proximal submucosal tunnel, the muscular layer of the affected esophagus is divided distally to the level of LES and cardia7. We perform the Heller myotomy using a robotic approach. The robotic platform offers enhanced high-definition visualization of distal esophageal and hiatal anatomy, advanced range of motion, and decreased complication rates when compared to the laparoscopic approach8. Despite all the advantages of the robotic approach, the method and approach to surgical treatment of achalasia decision ultimately lies with the surgeon and is dependent on the available resources, level of comfort, and experience with the available techniques. The goal of this protocol is to serve as a guide and a valuable resource for training new foregut surgeons, as well as residents, making the steps of the surgery clear and understandable.

<table><tbody><tr><td>8 mm assistance port</td><td>Da Vinci</td><td></td><td></td></tr><tr><td>Air Seal insuflation system</td><td>CONMED</td><td>Ias8-120LP</td><td></td></tr><tr><td>Force bipolar grasper</td><td></td><td></td><td></td></tr><tr><td>Forceps</td><td></td><td></td><td></td></tr><tr><td>Four 8-mm robotic ports</td><td>Da Vinci</td><td></td><td></td></tr><tr><td>Hook cautery.&amp;nbsp;</td><td>COVIDIEN</td><td>E3773-36C</td><td></td></tr><tr><td>Nathanson liver retractor</td><td>Mediflex</td><td>69704-3</td><td></td></tr><tr><td>Needle driver</td><td>COVIDIEN</td><td>172015</td><td></td></tr><tr><td>Robotic 30&amp;deg; endoscope</td><td>Da Vinci</td><td>470057</td><td></td></tr><tr><td>Robotic advanced bipolar device (Vessel Sealer)</td><td>INTUITIVE SURGICAL</td><td>480422</td><td></td></tr><tr><td>Two laparoscopic graspers</td><td>Stortv</td><td></td><td></td></tr></tbody></table>

robotic heller myotomy for advancements in surgical management of achalasia

Achalasia is an esophageal motility disorder. It occurs due to the destruction of nerves in the lower esophageal sphincter (LES), which leads to the failure of the LES to relax. Patients typically complain of dysphagia, chest pain, and regurgitation. They often report drinking liquids with solids intake to help propel food boluses into the stomach. The diagnosis of achalasia is typically confirmed with an esophagogram and a motility study (esophageal manometry). An esophagogram classically shows the bird beak sign with tapering in the distal esophagus. The treatment for achalasia includes both surgical and non-surgical options. Surgical treatment is associated with a lower rate of recurrences, high clinical success rate, and durability of symptom relief. The current gold standard of surgical technique is myotomy, or the dividing of the muscle fibers of the distal esophagus. Surgical myotomy can be accomplished via a laparoscopic or robotic technique; per-oral endoscopic myotomy is a new alternative intervention. Due to the theoretical risk of gastroesophageal reflux following a myotomy, an antireflux procedure is sometimes performed. We reviewed the approach to a robotic heller myotomy for the treatment of achalasia.

At our academic tertiary care center, both intraoperative and postoperative complications of Heller myotomy are extremely rare. Between 2020 and August 2023, post-Heller myotomy perforation rate was 0% utilizing the robotic approach. During this period, we performed 105 robotic Heller myotomy. Blood loss is generally less than 20 mL, and we did not transfuse blood for any patient; hospital stay length rarely exceeds postoperative day 1, and patients are able to drink immediately after surgery, experiencing relief of their achalasia symptoms. After the myotomy, we routinely perform intraoperative esophagogastroduodenoscopy (EGD) to evaluate the gastroesophageal (GE) junction. During this examination, we ensure that the endoscope can easily pass across the cardia (Figure 1B), and we can rule out any injury using a leak test. In recent years, we have begun to utilize endoluminal functional lumen imaging probes during the operation. Our patient was chosen randomly. She is a 67-year-old with a history of psoriatic arthritis and type II Achalasia. She had been suffering from progressive dysphagia, even after a previous attempt to treat it with Botox and dilation. The procedure (Heller myotomy) was performed successfully without any complications, and no blood transfusions were needed. She was able to drink immediately after the procedure and felt obvious relief from the dysphagia. After the surgery, she was discharged home on postoperative day 1. These results following surgery allow us to be confident of a safe and complete myotomy (Table 1). The radiographic evaluation of the upper GI series done before the operation and on post-operative day 1, showing the removal of the strictures and the absence of any leaks, is depicted in Figure 6.
<img alt="Endoscopic view, human mucosa, medical examination, image comparison, tissue analysis, endoscopy." class="xfigimg" src="/files/ftp_upload/66224/66224fig01.jpg" data-altupdatedat="1747911167000" data-alt="Figure 1"> 
Figure 1: Esophagogastroduodenoscopy. (A) Preoperative esophagogastroduodenoscopy (EGD) was used to visualize the severity of achalasia and rule out other findings (GEJ malignancy and other strictures). (B) Post-myotomy esophagogastroduodenoscopy (EGD) was able to pass the endoscope across the cardia easily, and no thermal injury was found. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/66224/66224fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Laparoscopic port placement diagram, surgical setup, abdominal measurements, precision incisions." class="xfigimg" src="/files/ftp_upload/66224/66224fig02.jpg" data-altupdatedat="1747911167000" data-alt="Figure 2"> 
Figure 2: Trocars placement. From the patient's left to right, the picture depicts the arrangement of 4 robotic trocars spaced approximately 8 cm apart. In addition, there is an assistant trocar positioned at the level of the right anterior axillary line. Furthermore, a Nathanson liver retractor is visible in the xiphoid region. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/66224/66224fig02large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Laparoscopic surgical technique diagram showing tissue stapling and measurement, 2-3 cm incision." class="xfigimg" src="/files/ftp_upload/66224/66224fig03.jpg" data-altupdatedat="1747911167000" data-alt="Figure 3"> 
Figure 3: Gastrohepatic ligament division. Division of the Gastrohepatic ligament, exposing the right cruse and phren-oesophageal membrane, using the bipolar energy device. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/66224/66224fig03large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Surgical technique, incision measuring 4-7 cm, clamp and cautery in use, detailed anatomy." class="xfigimg" src="/files/ftp_upload/66224/66224fig04.jpg" data-altupdatedat="1747911167000" data-alt="Figure 4"> 
Figure 4: Esophageal myotomy. The picture shows the application of traction using a robotic hook towards the anterior abdominal wall while carefully separating the muscle fibers of the esophagus until the esophageal mucosa becomes visible. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/66224/66224fig04large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Surgical technique diagram, highlighting nerve retraction, 6 cm measurement, anatomical precision." class="xfigimg" src="/files/ftp_upload/66224/66224fig05.jpg" data-altupdatedat="1747911167000" data-alt="Figure 5"> 
Figure 5: Complete esophageal myotomy. The picture illustrates a complete esophageal myotomy spanning at least 6 cm, highlighting the preservation of the anterior Vagus nerve branch indicated by an arrow. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/66224/66224fig05large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Chest X-ray and fluoroscopy illustrating esophageal process; diagnostic imaging comparison." class="xfigimg" src="/files/ftp_upload/66224/66224fig06.jpg" data-altupdatedat="1747911167000" data-alt="Figure 6"> 
Figure 6: Upper GI series. (A) This picture demonstrates a dilated esophagus and an EGJ stricture after ingesting barium during a GI series. (B) Following Heller myotomy, we can observe a significant relief in esophageal dilation and a significant improvement of the GEJ stricture with the passage of barium. Additionally, no evidence of a leak or free air was found. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/66224/66224fig06large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Age</td>
			<td>67 years</td>
		</tr>
		<tr>
			<td>Gender</td>
			<td>Female</td>
		</tr>
		<tr>
			<td>Race</td>
			<td>White or Caucasian</td>
		</tr>
		<tr>
			<td>BMI</td>
			<td>40</td>
		</tr>
		<tr>
			<td>Intraoperative</td>
			<td></td>
		</tr>
		<tr>
			<td>Operative time, min</td>
			<td>160 min</td>
		</tr>
		<tr>
			<td>Intraoperative blood loss, mL</td>
			<td>20 mL</td>
		</tr>
		<tr>
			<td>Postoperative</td>
			<td></td>
		</tr>
		<tr>
			<td>Postoperative complications</td>
			<td>None</td>
		</tr>
		<tr>
			<td>Hospital length of stay, days</td>
			<td>2</td>
		</tr>
		<tr>
			<td>Discharge, postoperative day (POD)</td>
			<td>POD 1</td>
		</tr>
	</tbody>
</table>
Table 1: Patient demographic and operation parameters.

Read this Scientific Article Protocol about Author Spotlight: Cutting-Edge Robotic Heller Myotomy Protocol for Treatment of Achalasia at JoVE.com

Author Spotlight: Cutting-Edge Robotic Heller Myotomy Protocol for Treatment of Achalasia

The protocol presents a robotic approach to Heller myotomy for the treatment of achalasia.

Robotic Heller Myotomy for Advancements in Surgical Management of Achalasia

Achalasia is an esophageal motility disorder. It occurs due to the destruction of nerves in the lower esophageal sphincter (LES), which leads to the ...

robotic-heller-myotomy-for-advancements-surgical-management

Nanyang Technological University

Research

JoVE Journal

Medicine

615 Views.  University of South Florida. The protocol presents a robotic approach to Heller myotomy for the treatment of achalasia. 

Video: Author Spotlight: Cutting-Edge Robotic Heller Myotomy Protocol for Treatment of Achalasia

Surgical Management of Meatal Stenosis with Meatoplasty

Meatal stenosis is a common urologic complication after circumcision. Children present to their primary care physicians with complaints of deviated urinary stream, difficult-to-aim, painful urination, and urinary frequency. Clinical exam reveals a pinpoint meatus and if the child is asked to urinate, he will usually have an upward, thin, occasionally forceful urinary stream with incomplete bladder emptying. The mainstay of management is meatoplasty (reconstruction of the distal urethra /meatus). This educational video will demonstrate how this is performed.

Meatoplasty, surgical management of meatal stenosis.

Meatal stenosis is a common urologic complication after circumcision.  Children present to their primary care physicians with complaints of deviated ...

Robotic Taj Mahal Hepatectomy for Hilar Cholangiocarcinoma

Hilar cholangiocarcinoma is the most common malignant tumor of the biliary tract. Radical surgical resection is the only effective treatment option. In this study, a 32-year-old male patient with Bismuth Type IVa hilar cholangiocarcinoma underwent radical robotic resection of hepatic S4b, S5, and S1 (Taj Mahal hepatectomy) combined with regional lymphadenectomy, hilar bile duct reconstruction, and hepaticojejunostomy by the robotic surgical system. Postoperative pathological examination showed moderately-differentiated adenocarcinoma of the hilar bile duct. The surgical margins of the liver and bile ducts were negative. Recovery was smooth and the patient was discharged on the 17th postoperative day. The robotic surgical system and associated multiple instruments along with flexible and precise movements is suitable for the local hepatectomy around the porta hepatis, and delicate reconstruction of the hilar bile duct with a smaller diameter. This first clinical application study found that robotic Taj Mahal hepatectomy for hilar cholangiocarcinoma is safe and feasible and needs more experience for the evaluation of its long-term outcomes.

Robotic resection of hepatic S4b, S5, and S1 using the Taj Mahal procedure is feasible and safe for selected patients with hilar cholangiocarcinoma. The step-by-step details for this surgery are presented here.

Hilar cholangiocarcinoma is the most common malignant tumor of the biliary tract. Radical surgical resection is the only effective treatment option. In ...

Use of the Scissor-Type Knife During the Peroral Endoscopy Myotomy Procedure for the Treatment of Achalasia

Peroral endoscopic myotomy (POEM) is one of the first-line treatment modalities along with pneumatic dilation and Heller myotomy for patients with achalasia. Endoscopists, especially trainees during the learning phase, commonly face difficulty in tissue plane dissection and selective myotomy while working near the esophagogastric junction, with increased risks of inadvertent injury, unexpected bleeding, and inadequate myotomy. To minimize the technical difficulty and improve the safety of POEM, we describe a protocol for using a scissor-type knife for the main steps of POEM, including mucosal incision, submucosal tunneling, myotomy, and hemostasis. The standard techniques used with the scissor-type knife involve grasping the target tissue, and then dissection or coagulation. The confirmation of the cutting line after grasping improves the accuracy and reliability of dissection, which is particularly useful for the selective myotomy of the internal circular muscle. Meanwhile, the scissor-type knife provides enhanced hemostatic capability and enables hemostasis and pre-coagulation without the device exchange for hemostatic forceps. Evaluation of the clinical outcomes in three patients who successfully received POEM using the scissor-type knife revealed no perioperative adverse events. At the 3-month follow-up, all patients achieved clinical success with postoperative Eckardt scores ranging from 0 to 1. In conclusion, the use of a scissor-type knife could minimize the technical difficulty and improve the safety of the POEM procedures, which may be suitable for trainees during the learning phase.

To minimize the technical difficulty and improve the safety of peroral endoscopic myotomy (POEM), we describe a protocol for using a scissor-type knife for the main steps of POEM, including mucosal incision, submucosal tunneling, myotomy, and hemostasis.

Peroral endoscopic myotomy (POEM) is one of the first-line treatment modalities along with pneumatic dilation and Heller myotomy for patients with ...

Robotic Myotomy and Partial Fundoplication for Achalasia

Laparoscopic Heller myotomy is currently considered the standard definitive treatment of achalasia. With the advancements in technology, robotic Heller myotomy has emerged as an alternative approach to traditional laparoscopy due to three-dimensional (3D) visualization, fine motor control, and improved ergonomics provided by the robot. 
Although there is a lack of randomized controlled trials, robotic-assisted Heller myotomy seems to be associated with lower rates of intraoperative perforations compared to the laparoscopic approach. A robotic approach may also improve surgical outcomes by providing a more complete myotomy. 
Here, we describe the detailed steps of robotic myotomy and partial fundoplication for achalasia.

Surgical myotomy with a partial fundoplication may be used in selected patients as a definitive treatment for achalasia. This article provides a step-by-step description of a robotic myotomy and partial fundoplication in a 32-year-old patient with megaesophagus.

Laparoscopic Heller myotomy is currently considered the standard definitive treatment of achalasia. With the advancements in technology, robotic Heller ...

Reoperative Hiatal Hernia Repair

Technical Considerations and Approach to Redo Foregut Surgery

Foregut surgical techniques have advanced significantly over the years and have become increasingly popular. However, new challenges and technical considerations have arisen when dealing with reoperation for complications or surgical failure. This study focuses on the technical considerations and approach when dealing with reoperative foregut surgery, particularly redo&#160;hiatal hernia repair. We describe our approach starting from the preoperative workup to the procedural steps of the surgery. The present study describes the main steps for robotic reoperative hiatal hernia repair in a patient who had previously undergone laparoscopic hiatal hernia repair with Nissen fundoplication but did not present a recurrence of reflux and dysphagia symptoms. The patient is positioned supine with arms out and a footboard for steep Trendelenburg. We place six trocars, including an assistant port and a liver retractor port,&#160;to facilitate visualization and retraction. After docking the robot, we use a combination of electrocautery and sharp dissection&#160;to free the hernia sac and reduce the hiatal hernia. The previous fundoplication is then taken down carefully and the esophagus is mobilized through a transhiatal approach with a combination of blunt and sharp dissection until at least 3 cm of intra-abdominal esophageal length is achieved, after which a leak test is performed. We then perform a crural repair to reapproximate the hiatus with two posterior stitches and one anterior stitch. Lastly, a redo Nissen fundoplication is performed over a bougie, and endoscopy is used to confirm a loose stack-of-coin appearance. By emphasizing the crucial steps of redo hiatal hernia repair, including preoperative evaluation, our goal is to provide an approach for the foregut surgeon to maximize patient outcomes.

Author Spotlight: Recent Advancements in Reoperative Foregut Surgery

Redo foregut surgery is associated with increased patient morbidity and presents a technical challenge for the surgeon. We describe our approach and considerations when performing a redo hiatal hernia repair to provide a guide for other surgeons and improve patient outcomes.

Foregut surgical techniques have advanced significantly over the years and have become increasingly popular. However, new challenges and technical ...

Surgical Treatment of Gastroparesis

Gastroparesis and intestinal dysmotility are life-altering diagnoses with no cure. Lifestyle changes, pharmacological, and surgical interventions are combined in a multidisciplinary fashion to improve the quality of life in this patient population. Starting with lifestyle changes, adjustments are made to the types and amounts of food consumed, medical conditions are optimized, and the use of narcotic pain medications as well as smoking is discontinued. For many, these changes are not enough, and antiemetics and promotility agents are used to control symptoms. Finally, when these measures fail, patients turn to surgery, which can include surgical alterations to the stomach, implantation of a gastric stimulator, placement of drainage tubes, and possibly even the complete removal of different organs, including the stomach or gallbladder. In our clinic, patients not only see a surgeon but also a gastroenterologist, dietitian, and psychologist. We strongly believe in a multidisciplinary approach to this condition. The goal is to provide patients with hope and help them live fuller and happier lives.
The study primarily addresses technical considerations and the surgical approach for patients diagnosed with gastroparesis. It outlines the entire process, starting from preparations before the surgery, encompassing the preoperative work-up, and detailing the steps involved in the surgical procedure. One of the key diagnostic challenges faced in treating gastroparesis patients is determining the underlying cause of the condition, as this information is critical for selecting the appropriate surgical intervention. Once the patient&#39;s condition has been categorized based on the cause, the medical team engages in a discussion with the patient regarding potential treatment options, which may include endoscopic procedures, minimally invasive techniques, or open surgery.

Gastroparesis is a condition in which the stomach does not empty properly. While it is initially managed with lifestyle modifications and medications, some patients eventually require surgical intervention. This study focuses on the technical considerations and surgical approaches for dealing with gastroparesis patients, which include endoscopic, minimally-invasive, and open surgical techniques.

Gastroparesis and intestinal dysmotility are life-altering diagnoses with no cure. Lifestyle changes, pharmacological, and surgical interventions are ...

Robotic Vagus-Sparing Total Gastrectomy for CDH1 Gene Mutation Treatment

Hereditary diffuse gastric cancer (HDGC) caused by the CDH1 gene mutation is an inherited cancer syndrome that increases the risk of diffuse gastric cancer and is nearly impossible to detect by screening gastroscopy. The recommended preventative treatment is a total gastrectomy. Robotic surgery facilitates the use of minimally invasive surgical (MIS) techniques for anastomoses and posterior vagus preservation to potentially reduce adverse functional outcomes. An asymptomatic 24 year old male with the CDH1 gene mutation proven by genetic testing and a family history of a brother having a total gastrectomy for HDGC was treated with this technique. This video case report demonstrates the techniques and pitfalls of robotic surgery in terms of the patient positioning and port placement, posterior vagus-preserving dissection, sutured esophagojejunostomy, jejunal pouch formation, and Roux-en-Y reconstruction with a staple-stapled jejunojejunostomy. While these techniques are demonstrated in the case of prophylactic gastrectomy, many of them can be applied to other benign and bariatric foregut and general surgery types.Robotic surgery can facilitate the foregut MIS technique, as described in this case of a vagus-sparing total gastrectomy.

This article focuses on robotic vagus-sparing total gastrectomy. The techniques and pitfalls of vagus preservation, sutured esophagojejunostomy, jejunal pouch formation, and Roux-en-Y reconstruction with a staple-stapled jejunojejunostomy are discussed.

Hereditary diffuse gastric cancer (HDGC) caused by the CDH1 gene mutation is an inherited cancer syndrome that increases the risk of diffuse gastric ...

Robotic D3 Partial Duodenal Resection with Primary Side-to-Side Anastomosis

Duodenal stenosis is a condition that can be related to several diseases, being either intrinsic, such as neoplasm and inflammatory stenosis, or extrinsic, such as pancreatic pseudocyst, superior mesenteric artery syndrome, and foreign bodies. Current treatments range from endoscopic approaches, such as endoscopic resection and stent placement, to surgical approaches, including duodenal resection, pancreaticoduodenectomy, and gastrointestinal bypass. Minimally invasive robot-assisted surgery is gaining importance due to its potential to decrease surgical stress, intraoperative blood loss, and postoperative pain, while its instruments and 3D-vision facilitate fine dissection and intra-abdominal suturing, all leading to a reduced time to functional recovery and shorter hospital stay. We present a case of a 75-year-old female who underwent robotic D3 partial duodenal resection with primary side-to-side duodeno-jejunal anastomosis for a 5 cm adenoma with focal high-grade dysplasia.

This protocol presents a case of a robotic partial duodenal resection with primary side-to-side duodeno-jejunal reconstruction in a patient with a 5 cm duodenal stenosis. This is done at the third duodenal segment (D3) after an endoscopic mucosal resection (EMR) for a duodenal polyp.

Duodenal stenosis is a condition that can be related to several diseases, being either intrinsic, such as neoplasm and inflammatory stenosis, or ...

Surgical Management of Persistent or New Symptoms After Hiatal Hernia Repair

Following a hiatal hernia repair, patients can present with recurrent or new symptoms. Symptoms can occur anywhere from weeks to years after surgery. These may include recurrent reflux, dysphagia, regurgitation, weight loss, or deteriorating quality of life. While nonoperative management can be pursued in some patients, reoperation may be the only option in select patients. A thorough preoperative workup, including a repeat esophagram, upper endoscopy, +/- chest computed tomography (CT) scan, manometry, pH probe, and/or gastric emptying study, is warranted to better understand the pathophysiology of the presenting symptoms. If a recurrent hernia, slipped, or migrated wrap is identified, surgery is considered. Pseudoachalasia must also be ruled out if obstructive symptoms are observed at the hiatus. Such an exhaustive workup is indeed necessary to ensure accurate diagnosis and optimal outcome. In addition, an understanding of the factors that may have led to the recurrence will increase the chances of a successful reoperation. Although a technically demanding procedure, redo hiatal hernia repair utilizing a minimally invasive approach is increasingly being employed with promising outcomes. Herein, the steps of a redo hiatal hernia repair via a minimally invasive approach will be outlined and detailed.

Redo foregut surgery is challenging in today's clinical practice and is fraught with increased morbidity and reportedly a lower 'success' rate than the index procedure. Here, we present a protocol for a redo hiatal hernia repair via a minimally invasive approach.

Following a hiatal hernia repair, patients can present with recurrent or new symptoms. Symptoms can occur anywhere from weeks to years after surgery. ...

Robotics in Surgery: A Modular Robotic Platform Driven Gastric Wedge Resection

Robotic-assisted surgery has become increasingly popular since the introduction of the first robotic platform. Recently, a modular robotic system was approved for in-human use in Europe. Possible applications for this new robotic system are being explored, and standardized approaches are evolving. In lieu of this, a gastric wedge resection and the standardized setup for upper gastrointestinal procedures using this new system are presented here. This safe and feasible robotic procedure is demonstrated in a 69-year-old patient with a gastric tumor. All steps of the surgery are described in a detailed and reproducible manner. The article also details trocar positioning, arm adjustments, and required surgical instruments. Docking time amounted to 13 min, whereas the console time took 115 min. The patient was discharged after 4 days after ensuring an uneventful course. The presented method is also suitable for other surgical purposes, such as fundoplications or hiatoplasties, and ensures both generalizability and reproducibility.

Robotically assisted surgery has become highly popular in recent years. Presented here is the standard care for upper gastrointestinal procedures, including a demonstration of a robotic-assisted gastric wedge resection using a modular robotic device.

Robotic-assisted surgery has become increasingly popular since the introduction of the first robotic platform. Recently, a modular robotic system was ...